=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467878090
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAURA DUNNICK
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/06/2014
-----------------------------------------------------
Last Update Date | 10/29/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10660 PARK RD STE 3200
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28210-8420
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 46-672-5007
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6307 BEVINGTON PL
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28277-3537
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 337-794-9222
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT871617
-----------------------------------------------------
License Number State | DC
-----------------------------------------------------